EVIDENCE

A link between urbanisation and diabetes exists

Cities provide tremendous opportunity for studying and understanding
the drivers behind type 2 diabetes. Cities are highly complex and
dynamic and differ considerably in relation to urbanisation rate, and
population size and density. Furthermore, most cities consist of both
wealthy and poor and deprived areas. These vital differences between
and within cities make it challenging to generalise on how city life
implement health. Specific city characteristics may affect certain
diseases adversely, while other characteristics may offer protection
and a complex interrelationship between the characteristics makes it
extremely difficult to predict the exact impact and generalise on how
city life implement health.

Extensive research has been performed in five cities from 2014 to
2016: Mexico City, Copenhagen, Houston, Tianjin and Shanghai. Research
has also been initiated in Johannesburg, Vancouver and Rome - and more
cities are expected to conduct research as they join the programme.

These are cities with a combined population of almost 70 million
people. They represent the characteristics of rapidly growing cities
of emerging economies and more mature cities of the developed world:
all of them faced with the challenge of a growing number of people
with diabetes resulting in a growing economic burden for society.

METHODOLOGY

Quantitative research

RULE OF HALVES

The aim of the quantitative research is to estimate the extent of
the diabetes burden in each city and define where the greatest
challenges are in relation to diagnosis and/or treatment. We use the
so-called “Rule of Halves” (RoH). 1 2

RoH is a framework used in various chronic diseases and it
originally states that half the people with a chronic disease are not
diagnosed, half of those diagnosed are not receiving care, half of
those receiving care are not controlled.1 The first term of
the rule of halves was suggested in the USA in 1947 for non-insulin
dependent diabetes3 and in 1964 confirmed in the
UK.4 The second term of the rule of halves for diabetes was
added in 19765 and in 1980, the third term was established.6

The rule of halves still largely holds true for most chronic
diseases.7 For this programme the RoH is adapted and two
additional terms are included: half the people with diabetes are not
diagnosed, half of those diagnosed are not receiving care, half of
those receiving care are not achieving treatment targets, and half of
those achieving treatment targets are not achieving the desired
outcome (no complications).

Hart JT. Rule of halves: implications of increasing diagnosis
and reducing dropout for future workload and prescribing costs in
primary care. The British journal of general practice : the journal
of the Royal College of General Practitioners 1992;42:116-9.

Wilkerson HL,
Krall LP. Diabetes in a New England town: a study of 3,516 persons
in Oxford, Mass. Journal of the American Medical Association
1947;135:209-16.

Sharp C. Diabetes survey in
Bedford 1962. Proceedings of the Royal Society of Medicine
1964;57:193.

Doney BJ. An audit of the care
of diabetics in a group practice. The Journal of the Royal College
of General Practitioners 1976;26:734.

Wilkes
E, Lawton EE. The diabetic, the hospital and primary care. The
Journal of the Royal College of General Practitioners
1980;30:199.

Mufunda J, Ghebrat Y, Usman A,
et al. Underestimation of prevalence of raised blood sugar from
history compared to biochemical estimation: support for the WHO rule
of halves in a population based survey in Eritrea of 2009.
SpringerPlus 2015;4:723.

Qualitative research

VULNERABILITY ASSESSMENT

The aim of the qualitative research is to understand what makes
certain people vulnerable to type 2 diabetes and its complications.
This makes it possible to go beyond the Rule of Halves results by
exploring the socio-cultural drivers of type 2 diabetes in cities.

To serve this aim a Diabetes Vulnerability Assessment (D-VA) was
designed based on an established Vulnerability Assessment (VA) tool
developed previously by the academic lead at University College London
in collaboration with the Unites Nations.1

The D-VA is tailored to each city to accommodate local circumstances
and local language. Each local academic partner carries out data
collection and performs analyses to identify relevant local factors
that impact how health and wellbeing are experienced amongst
individuals at local levels. Global analyses are conducted by the
global academic lead at UCL to identify globally salient themes and
develop a global set of social factors and cultural determinants based
on the locally conducted D-VA.

In total, 740 interviews have been conducted in the first five cities.

To expand and further strengthen the global research platform, the
Cities Changing Diabetes (CCD) programme is in the process of
developing a new research tool. The Diabetes Q-Study Tool (D-Q) will
enable new cities to better understand local specific social and
cultural factors related to health, well-being and diabetes.

The D-Q tool utilizes Q-methodology23 and
builds on the findings of the Diabetes Vulnerability Assessment (D-VA).

The D-Q tool principally answers two overall questions:

Which social factors and cultural determinants matter most
among the respondents in regards to their health, wellbeing, and
diabetes experience.

Why these social
factors and cultural determinants are important and how they shape
health and diabetes among subgroups of a city’s citizens.

The D-Q tool enables cities to establish local research platform
that can inform interventions and policies, at the same time
contributing to further strengthen the global research platform.

The D-Q tool will be pilot-tested in Vancouver in the beginning of 2017.

The Tripartite Core Group. Post-Nargis Periodic Review I: the
Association of Southeast Asian Nations (ASEAN), the Government of
the Union of Myanmar and the United Nations, 2008.

Stephenson, W. The Study of Behavior: Q Technique and its
Methodology. Chicago: University of Chicago Press. 1953.